Can a hemorrhoid be surgically removed after lancing?

Surgical Management of Hemorrhoids After Lancing

Yes, a hemorrhoid can be surgically removed after lancing, particularly when the initial lancing procedure fails to provide adequate symptom relief or when complications persist. 1

Understanding Hemorrhoid Treatment Progression

Hemorrhoid management follows a stepwise approach based on severity:

1. Conservative management - For first and second-degree hemorrhoids
2. Office-based procedures - For persistent first, second, and some third-degree hemorrhoids
3. Surgical intervention - For third and fourth-degree hemorrhoids or when other treatments fail

When Surgical Removal After Lancing is Appropriate

Lancing (incision and drainage) is typically performed for thrombosed external hemorrhoids to provide immediate pain relief. Surgical hemorrhoidectomy after lancing may be indicated in the following scenarios:

• Persistent symptoms despite lancing
• Recurrent thrombosis
• Extensive hemorrhoidal disease
• Failure of conservative management
• Patient preference 1

Surgical Options After Lancing

Conventional Hemorrhoidectomy

Two main approaches exist:

1. Milligan-Morgan (Open) Hemorrhoidectomy:

   • Internal and external components are excised
   • Skin is left open in a 3-leaf clover pattern
   • Healing occurs secondarily over 4-8 weeks 1

2. Ferguson (Closed) Hemorrhoidectomy:

   • Hemorrhoid components are excised
   • Wounds are closed primarily
   • May offer slightly decreased pain and faster return to work 1

Advanced Surgical Techniques

1. Stapled Hemorrhoidopexy (Longo Procedure):

   • Removes a ring of redundant rectal mucosa above the anal canal
   • Resuspends prolapsing hemorrhoidal tissue
   • Less postoperative pain than conventional techniques
   • Faster recovery but higher recurrence rate 1

2. Hemorrhoidal Artery Ligation (HAL):

   • Can be combined with Recto-Anal Repair (RAR)
   • Better tolerated but higher recurrence rate 2

Important Considerations

Postoperative Bleeding Management

• Small amounts of bleeding are normal during the early post-operative period
• Bleeding requiring medical attention includes: heavy/continuous bleeding, large blood clots, bleeding with severe pain, or bleeding persisting beyond 2 weeks 3

Potential Complications

Surgical hemorrhoidectomy has several potential complications:

• Urinary retention (2-36%)
• Bleeding (0.03-6%)
• Anal stenosis (0-6%)
• Infection (0.5-5.5%)
• Incontinence (2-12%) 1

Pain Management

Postoperative pain is the major drawback of excisional hemorrhoidectomy:

• Narcotic analgesics are generally required
• Most patients need 2-4 weeks before returning to work
• Various techniques (diathermy, local anesthetics, metronidazole) may help reduce pain 1

Special Situations

Emergency Hemorrhoidectomy

For acutely thrombosed or strangulated hemorrhoids:

• Can be performed safely with results comparable to elective procedures
• A randomized trial showed that both Milligan-Morgan hemorrhoidectomy and incision with rubber band ligation can be safely performed in acute cases 1

Decision Algorithm

1. After lancing a thrombosed hemorrhoid:

   • Monitor for 2-3 weeks for symptom resolution
   • If symptoms persist or recur, consider definitive surgical management

2. For surgical decision-making:

   • Grade III-IV hemorrhoids → Surgical hemorrhoidectomy
   • Failed office-based procedures → Surgical hemorrhoidectomy
   • Patient preference for definitive treatment → Surgical hemorrhoidectomy

3. Technique selection:

   • For standard cases → Ferguson (closed) technique preferred due to potentially less pain
   • For circular hemorrhoids → Stapled hemorrhoidopexy
   • For patients concerned about pain → Consider stapled or HAL/RAR approaches

Remember that approximately 5-10% of hemorrhoid patients will ultimately require surgical hemorrhoidectomy, usually those with third or fourth-degree hemorrhoids 1.